Rheumatology and Immunology — MCQs
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A 55-year-old man presented with pain and swelling of his right great toe. The pain has been present for approximately 2 days and is worsening. He had a similar episode 4 years ago, but has been symptom-free since then. He denied trauma, fever, chills, or sweats and has been afebrile. On physical examination, his right great toe is swollen at the metatarsophalangeal joint with decreased range of motion. X-ray films are unrevealing and there was no other joint involvement. A joint aspiration is performed. Which of the following types of crystals in the joint aspirate would confirm the likely diagnosis?
A 50-year-old female with rheumatoid arthritis is being considered for infliximab therapy. Which of the following tests should be performed before beginning treatment?
Involvement of the joints of the hand is relatively uncommon in which of the following arthritides?
A 65-year-old lady underwent mastectomy for carcinoma of the breast. Later, she developed frontal headache, pain in the temple region, and around the eye. Her ESR is 55 mm/hour. What is the most probable diagnosis?
A patient diagnosed with gout should be advised to avoid which of the following food products in their diet?
All of the following statements about primary gouty arthritis are true, EXCEPT?
What is the most common manifestation of arterial thrombosis in antiphospholipid antibody syndrome?
Erosive arthritis is seen in all, except?
A 71-year-old woman presents with a 3-month history of headaches, fatigue, and weight loss. The headaches are new and not severe. She also experiences jaw claudication. Two days prior, she experienced transient partial vision loss in her left eye, with no other neurological symptoms. Examination reveals a supple neck, normal fundi, and a normal neurological exam. Prednisone 60 mg/day was initiated, and a biopsy was performed to confirm the diagnosis. Which of the following is the most likely finding on the biopsy to confirm the diagnosis?
A 50-year-old man presents with a month of muscle pain and fever, noting darker colored urine for the past two weeks. Physical examination reveals palpable purpuric skin lesions. Urinalysis shows hematuria and proteinuria. Serum laboratory findings include mixed cryoglobulinemia with a polyclonal increase in IgG, and a high titer of antimyeloperoxidase (MPO-ANCA), also known as P-ANCA. A skin biopsy is performed. What pathologic finding is most likely to be observed in this biopsy?
Rheumatology and Immunology Indian Medical PG Practice Questions and MCQs
Question 551: A 55-year-old man presented with pain and swelling of his right great toe. The pain has been present for approximately 2 days and is worsening. He had a similar episode 4 years ago, but has been symptom-free since then. He denied trauma, fever, chills, or sweats and has been afebrile. On physical examination, his right great toe is swollen at the metatarsophalangeal joint with decreased range of motion. X-ray films are unrevealing and there was no other joint involvement. A joint aspiration is performed. Which of the following types of crystals in the joint aspirate would confirm the likely diagnosis?
- A. Negatively-birefringent needle-shaped crystals. (Correct Answer)
- B. Negatively-birefringent oval crystals.
- C. Negatively-birefringent rhomboidal shaped crystals.
- D. Positively-birefringent needle-shaped crystals.
Explanation: ### Explanation The clinical presentation of acute onset pain, swelling, and erythema of the first metatarsophalangeal (MTP) joint (known as **podagra**) in a middle-aged male is classic for **Gouty Arthritis**. The episodic nature (recurrent attacks with symptom-free intervals) further supports this diagnosis. **1. Why the Correct Answer is Right:** The definitive diagnosis of gout is made by identifying **Monosodium Urate (MSU) crystals** in the synovial fluid under polarized light microscopy [1]. These crystals are characteristically **needle-shaped** and exhibit **strong negative birefringence** [3]. This means they appear yellow when aligned parallel to the slow axis of the compensator and blue when perpendicular. **2. Analysis of Incorrect Options:** * **Option B:** Oval crystals are not characteristic of common crystal arthropathies. While some lipid crystals can be oval, they do not fit the clinical picture of podagra. * **Option C:** Rhomboidal crystals are characteristic of **Pseudogout** (Calcium Pyrophosphate Deposition Disease - CPPD), but they are typically *positively* birefringent [4]. * **Option D:** **Calcium Pyrophosphate (CPPD)** crystals are **rhomboid-shaped** and show **weak positive birefringence** (appearing blue when parallel to the compensator) [4]. **3. NEET-PG High-Yield Pearls:** * **Gold Standard Diagnosis:** Joint aspiration and crystal analysis (even if serum uric acid is normal during an acute attack). * **Radiology:** Early gout shows normal X-rays (as seen here). Chronic gout shows "punched-out" erosions with overhanging edges (**Martel’s sign**). * **Acute Management:** NSAIDs (first-line), Colchicine, or Corticosteroids. * **Chronic Management:** Xanthine oxidase inhibitors (Allopurinol, Febuxostat) are used for prophylaxis, but never initiated during an acute attack as they may worsen the flare [2].
Question 552: A 50-year-old female with rheumatoid arthritis is being considered for infliximab therapy. Which of the following tests should be performed before beginning treatment?
- A. Liver function tests
- B. PPD skin test (Correct Answer)
- C. Pulmonary function tests
- D. Visual examination
Explanation: **Explanation:** **1. Why the Correct Answer is Right:** Infliximab is a monoclonal antibody that inhibits **Tumor Necrosis Factor-alpha (TNF-alpha)**. TNF-alpha plays a critical role in the formation and maintenance of **granulomas**, which sequester *Mycobacterium tuberculosis*. By inhibiting TNF-alpha, infliximab can cause the breakdown of these granulomas, leading to the **reactivation of Latent Tuberculosis Infection (LTBI)**. Therefore, all patients must be screened for TB using a **PPD (Tuberculin) skin test** or an Interferon-Gamma Release Assay (IGRA) and a chest X-ray before initiating therapy [1]. If LTBI is detected, prophylactic treatment (e.g., Isoniazid) must be started before the biologic [1]. **2. Why the Incorrect Options are Wrong:** * **A. Liver Function Tests:** While some DMARDs (like Methotrexate) require rigorous LFT monitoring [2], they are not the primary mandatory screening requirement specifically unique to the initiation of TNF inhibitors compared to the risk of TB. * **C. Pulmonary Function Tests:** These are typically indicated before starting **Bleomycin** or if **Amiodarone** toxicity is suspected. While RA can cause interstitial lung disease, PFTs are not a prerequisite for starting Infliximab. * **D. Visual Examination:** This is mandatory for patients starting **Hydroxychloroquine (HCQ)** to screen for bull’s eye maculopathy, but it is not required for TNF inhibitors. **3. NEET-PG High-Yield Pearls:** * **TNF-alpha Inhibitors:** Include Infliximab, Adalimumab, Etanercept, Certolizumab, and Golimumab [2]. * **Contraindications:** Avoid TNF inhibitors in patients with **NYHA Class III/IV Heart Failure** and active infections. * **Vaccination:** Always ensure immunizations (especially pneumococcal and hepatitis B) are up to date; **live vaccines** are contraindicated once therapy begins. * **Screening:** Always screen for **Hepatitis B and C** alongside TB before starting biologics [1].
Question 553: Involvement of the joints of the hand is relatively uncommon in which of the following arthritides?
- A. Ankylosing spondylitis (Correct Answer)
- B. Reactive arthritis
- C. Psoriatic arthritis
- D. Rheumatoid arthritis
Explanation: **Explanation:** The correct answer is **Ankylosing Spondylitis (AS)**. **1. Why Ankylosing Spondylitis is correct:** Ankylosing spondylitis is the prototype of Seronegative Spondyloarthropathies (SpA) [2]. Its hallmark is **axial involvement**, primarily affecting the sacroiliac joints and the spine (ascending involvement) [4]. While peripheral arthritis occurs in approximately 30% of cases, it typically involves **large, proximal joints** (hips and shoulders). Involvement of the small joints of the hand is rare in AS compared to other inflammatory arthritides. **2. Why the other options are incorrect:** * **Rheumatoid Arthritis (RA):** This is the classic "hand-involved" arthritis. It characteristically involves the MCP, PIP, and wrist joints symmetrically [3], sparing the DIPs. * **Psoriatic Arthritis (PsA):** Small joints of the hand are frequently involved [1]. It is unique for involving the **DIP joints** and can cause "Dactylitis" (sausage digits) and *arthritis mutilans* [1]. * **Reactive Arthritis:** While it typically presents as an asymmetric oligoarthritis of the lower limbs (knees/ankles) [5], it frequently involves the fingers (dactylitis) and can manifest in the small joints of the hands during the acute phase. **Clinical Pearls for NEET-PG:** * **Symmetry:** RA is typically symmetric; SpA (Psoriatic, Reactive) is typically asymmetric. * **DIP Involvement:** Think Psoriatic Arthritis or Osteoarthritis (Heberden’s nodes). RA **never** involves the DIPs [3]. * **HLA Association:** AS has the strongest association with **HLA-B27** (>90%) [2]. * **Radiology High-Yield:** Look for "Bamboo spine" (AS), "Pencil-in-cup" deformity (PsA), and "Periarticular osteopenia" (RA) [4].
Question 554: A 65-year-old lady underwent mastectomy for carcinoma of the breast. Later, she developed frontal headache, pain in the temple region, and around the eye. Her ESR is 55 mm/hour. What is the most probable diagnosis?
- A. Cavernous sinus thrombosis
- B. Meningeal metastasis
- C. Frontal sinusitis
- D. Giant cell arteritis (Correct Answer)
Explanation: ### Explanation **Correct Option: D. Giant Cell Arteritis (GCA)** The clinical presentation of a **new-onset headache** in an elderly patient (age >50), specifically localized to the **temple and frontal region**, combined with an **elevated ESR** (>50 mm/hr), is a classic triad for Giant Cell Arteritis (also known as Temporal Arteritis) [1]. GCA is a large-vessel vasculitis that frequently involves the branches of the external carotid artery. The pain around the eye can be attributed to ischemia or referred pain [1]. In NEET-PG scenarios, any elderly patient with a high ESR and localized headache should be suspected of GCA to prevent permanent visual loss [2]. **Why other options are incorrect:** * **A. Cavernous Sinus Thrombosis:** This typically presents with high-grade fever, proptosis, chemosis, and cranial nerve palsies (III, IV, V1, V2, VI). While it causes eye pain, the systemic signs of sepsis and ophthalmoplegia are absent here. * **B. Meningeal Metastasis:** While possible given her history of breast cancer, it usually presents with more diffuse neurological deficits, signs of increased intracranial pressure (vomiting, papilledema), or multiple cranial nerve involvement rather than localized temporal pain [3]. * **C. Frontal Sinusitis:** This causes frontal headache and tenderness over the sinuses, but it is usually associated with nasal congestion, purulent discharge, and is less likely to be the primary diagnosis in a 65-year-old with a significantly raised ESR without respiratory symptoms. **High-Yield Clinical Pearls for NEET-PG:** * **Gold Standard Diagnosis:** Temporal artery biopsy (look for "skip lesions") [2]. * **Associated Condition:** Strongly associated with **Polymyalgia Rheumatica (PMR)** (proximal muscle stiffness) [2]. * **Urgent Management:** If GCA is suspected, start **high-dose corticosteroids** immediately to prevent blindness (anterior ischemic optic neuropathy); do not wait for biopsy results [2]. * **Key Lab:** ESR is usually >50 mm/hr, often >100 mm/hr [2]. CRP is also a sensitive marker.
Question 555: A patient diagnosed with gout should be advised to avoid which of the following food products in their diet?
- A. Whisky and beer
- B. Spinach and mushrooms
- C. Meat and fish
- D. All of the above (Correct Answer)
Explanation: Gout is a crystal arthropathy caused by the deposition of **monosodium urate crystals** [2] in joints, resulting from chronic hyperuricemia. The primary goal of dietary management in gout is to reduce the intake of **purines** [1], which are metabolically broken down into uric acid by the enzyme xanthine oxidase. * **Option A (Whisky and Beer):** Alcohol is a major trigger. **Beer** is particularly high in guanosine (a purine) and brewer’s yeast. Furthermore, alcohol metabolism increases lactic acid production, which competitively inhibits the renal excretion of uric acid [3]. * **Option B (Spinach and Mushrooms):** While plant-based purines were historically thought to be less significant, they are still classified as high-purine vegetables. Current guidelines suggest moderation, but for the purpose of standard medical examinations, they remain on the "avoid/restrict" list. * **Option C (Meat and Fish):** Red meats (beef, lamb) and organ meats (liver, kidney) are extremely rich in purines. Certain seafood (sardines, shellfish, anchovies) also significantly elevates serum urate levels. Since all three categories contribute to the purine load and exacerbate hyperuricemia, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** 1. **Drug of Choice:** NSAIDs (e.g., Indomethacin) are first-line for acute attacks [4]. Use Colchicine if NSAIDs are contraindicated. 2. **Urate-Lowering Therapy (ULT):** Allopurinol (Xanthine oxidase inhibitor) is the mainstay for chronic management but should **never** be started during an acute attack as it may worsen the inflammation. 3. **Dairy Paradox:** Low-fat dairy products actually have a **uricosuric effect** and are encouraged in gout patients. 4. **Fructose:** High-fructose corn syrup (found in sodas) is a non-purine trigger that increases uric acid production.
Question 556: All of the following statements about primary gouty arthritis are true, EXCEPT?
- A. 90% of cases are caused by overproduction of uric acid. (Correct Answer)
- B. Uric acid levels may be normal at the time of an acute attack.
- C. Men are more commonly affected than women.
- D. Definitive diagnosis requires aspiration of synovial fluid.
Explanation: **Explanation:** **1. Why Option A is the correct answer (The False Statement):** In primary gout, the underlying pathophysiology is hyperuricemia. However, **90% of cases are caused by under-excretion of uric acid** by the kidneys [1], rather than overproduction. Only about 10% of cases are due to the overproduction of uric acid (often associated with enzyme defects like HGPRT deficiency or PRPP synthetase overactivity) [2]. **2. Analysis of other options:** * **Option B:** It is a classic clinical trap. Serum uric acid levels can be **normal or even low** during an acute attack because inflammatory cytokines increase the renal excretion of uric acid. Therefore, a normal level does not rule out an acute flare. * **Option C:** Gout shows a strong male predilection (approx. 7:1 to 9:1 ratio). Estrogen has **uricosuric effects**, which protects premenopausal women; hence, gout in women typically occurs only after menopause. * **Option D:** The "Gold Standard" for definitive diagnosis is the visualization of **monosodium urate (MSU) crystals** in synovial fluid using compensated polarized light microscopy [1]. **Clinical Pearls for NEET-PG:** * **Crystal Morphology:** MSU crystals are **needle-shaped** and show **strong negative birefringence** (they appear yellow when parallel to the slow axis of the compensator). * **First-line for Acute Gout:** NSAIDs (e.g., Indomethacin) or Colchicine. * **Chronic Management:** Xanthine oxidase inhibitors (Allopurinol, Febuxostat) are used for urate-lowering therapy [1], but they should **never** be started during an acute attack as they may worsen the flare. * **Radiology:** "Punced-out" erosions with overhanging edges (**Martel’s sign**) are characteristic of chronic tophaceous gout [3].
Question 557: What is the most common manifestation of arterial thrombosis in antiphospholipid antibody syndrome?
- A. Stroke (Correct Answer)
- B. Transient ischemic attacks
- C. Myocardial ischemia
- D. Amaurosis fugax
Explanation: **Explanation:** Antiphospholipid Antibody Syndrome (APS) is an autoimmune prothrombotic state characterized by recurrent venous or arterial thrombosis and pregnancy complications. **1. Why Stroke is Correct:** In the arterial system, the **central nervous system** is the most frequent site of involvement. Among all arterial events in APS, **ischemic stroke** is the most common manifestation [1]. It typically presents in young individuals (often <45 years) without traditional cardiovascular risk factors. The pathogenesis involves a "two-hit" mechanism where antiphospholipid antibodies (aPL) activate endothelial cells, platelets, and the complement cascade, leading to a hypercoagulable state. **2. Why other options are incorrect:** * **Transient Ischemic Attacks (TIAs):** While common in APS, they occur less frequently than completed strokes [1]. TIAs are often precursors or associated symptoms rather than the primary manifestation. * **Myocardial Ischemia:** This is the second most common site of arterial thrombosis in APS. While significant, its prevalence remains lower than cerebrovascular events. * **Amaurosis Fugax:** This is a specific type of transient retinal ischemia [1]. While a recognized feature of APS, it is a localized manifestation and far less common than a generalized stroke. **High-Yield Clinical Pearls for NEET-PG:** * **Most common overall manifestation of APS:** Deep Vein Thrombosis (DVT) – *Note: Venous thrombosis is more common than arterial.* * **Most common arterial manifestation:** Stroke. * **Diagnostic Criteria (Sapporo/Sydney):** Requires at least one clinical (thrombosis or pregnancy loss) and one laboratory criterion (Lupus anticoagulant, Anti-cardiolipin, or Anti-β2 glycoprotein I antibodies) positive on two occasions 12 weeks apart. * **Libman-Sacks Endocarditis:** A classic association involving sterile vegetations on heart valves (mitral > aortic).
Question 558: Erosive arthritis is seen in all, except?
- A. Systemic Lupus Erythematosus (SLE) (Correct Answer)
- B. Gout
- C. Osteoarthritis
- D. Old age
Explanation: The core concept in this question is distinguishing between **erosive** (bone-destroying) and **non-erosive** arthropathies. **1. Why SLE is the correct answer:** Arthritis in **Systemic Lupus Erythematosus (SLE)** is characteristically **non-erosive** [1]. While it can be painful and involve small joints (mimicking Rheumatoid Arthritis), it does not cause marginal bone erosions on X-ray. A classic manifestation is **Jaccoud’s Arthropathy**, where joint deformities (like ulnar deviation) occur due to ligamentous laxity and tendon inflammation rather than bone destruction. These deformities are typically reducible. **2. Analysis of Incorrect Options:** * **Gout:** Chronic tophaceous gout is a classic cause of **erosive arthritis**. It produces characteristic "punched-out" erosions with overhanging edges (Martel’s sign) due to urate crystal deposition. * **Osteoarthritis (OA):** While primarily degenerative, a specific subtype called **Erosive Osteoarthritis** (typically affecting DIP and PIP joints) exists, characterized by "gull-wing" or "sawtooth" erosions on imaging [1]. * **Old Age:** This is a distractor often used to imply **Osteoarthritis** (the most common joint disease in the elderly), which, as mentioned above, can present with erosive changes in specific inflammatory variants. **Clinical Pearls for NEET-PG:** * **Non-Erosive Arthritis:** SLE, Rheumatic Fever, Mixed Connective Tissue Disease (MCTD). * **Erosive Arthritis:** Rheumatoid Arthritis (RA), Psoriatic Arthritis, Gout, Erosive OA, Ankylosing Spondylitis [1]. * **Jaccoud’s Arthropathy:** Key buzzword for SLE; remember it is **reducible** and **non-erosive**. * **Most common joint involved in SLE:** Small joints of the hands (PIP, MCP) and wrists.
Question 559: A 71-year-old woman presents with a 3-month history of headaches, fatigue, and weight loss. The headaches are new and not severe. She also experiences jaw claudication. Two days prior, she experienced transient partial vision loss in her left eye, with no other neurological symptoms. Examination reveals a supple neck, normal fundi, and a normal neurological exam. Prednisone 60 mg/day was initiated, and a biopsy was performed to confirm the diagnosis. Which of the following is the most likely finding on the biopsy to confirm the diagnosis?
- A. Immune complex deposition
- B. Arteritis with giant cells (Correct Answer)
- C. Lymphocytic infiltration
- D. Type II muscle fiber atrophy
Explanation: ### Explanation The clinical presentation of a 71-year-old patient with new-onset headaches, jaw claudication, constitutional symptoms (weight loss, fatigue), and transient monocular vision loss (amaurosis fugax) is classic for **Giant Cell Arteritis (GCA)**, also known as Temporal Arteritis. **1. Why the Correct Answer is Right:** GCA is a systemic granulomatous vasculitis [1]. The gold standard for diagnosis is a temporal artery biopsy [1]. The characteristic histopathological finding is **panarteritis** featuring inflammatory infiltrates (macrophages, lymphocytes, and T-cells) with **fragmentation of the internal elastic lamina** and the presence of **multinucleated giant cells** [1]. **2. Why Incorrect Options are Wrong:** * **A. Immune complex deposition:** This is characteristic of Type III hypersensitivity reactions (e.g., Systemic Lupus Erythematosus or Polyarteritis Nodosa), whereas GCA is a T-cell-mediated (Type IV) hypersensitivity. * **C. Lymphocytic infiltration:** While lymphocytes are present in GCA, this is a non-specific finding seen in many inflammatory conditions [1]. The presence of giant cells and granulomatous inflammation is the pathognomonic feature for GCA. * **D. Type II muscle fiber atrophy:** This is a common finding in **Corticosteroid-induced myopathy** or disuse atrophy, not a diagnostic feature of vasculitis. **3. Clinical Pearls for NEET-PG:** * **Association:** ~50% of GCA patients also have **Polymyalgia Rheumatica (PMR)** (proximal muscle pain/stiffness) [1]. * **Diagnosis:** Elevated ESR (often >100 mm/hr) and CRP are highly sensitive [1]. * **Management:** If GCA is suspected, **start high-dose steroids immediately** to prevent permanent blindness; do not wait for biopsy results [1]. * **Biopsy Fact:** Due to "skip lesions," a long segment of the artery (3–5 cm) should be biopsied to avoid false negatives [1].
Question 560: A 50-year-old man presents with a month of muscle pain and fever, noting darker colored urine for the past two weeks. Physical examination reveals palpable purpuric skin lesions. Urinalysis shows hematuria and proteinuria. Serum laboratory findings include mixed cryoglobulinemia with a polyclonal increase in IgG, and a high titer of antimyeloperoxidase (MPO-ANCA), also known as P-ANCA. A skin biopsy is performed. What pathologic finding is most likely to be observed in this biopsy?
- A. Giant cells and macrophages
- B. Medial fibrinoid necrosis (Correct Answer)
- C. Micro abscesses
- D. Mycotic aneurysms
Explanation: ### **Explanation** The clinical presentation of fever, muscle pain, palpable purpura, and renal involvement (hematuria/proteinuria) associated with **P-ANCA (MPO-ANCA)** strongly suggests a **Small Vessel Vasculitis**, most likely **Microscopic Polyangiitis (MPA)**. **1. Why the Correct Answer is Right:** The hallmark pathologic feature of systemic necrotizing vasculitis (like MPA or Polyarteritis Nodosa) is **segmental fibrinoid necrosis of the media**. In the acute phase, the vessel wall undergoes destruction and is replaced by eosinophilic, proteinaceous material (fibrin, immunoglobulins, and complement), known as fibrinoid necrosis. This is accompanied by an infiltrate of neutrophils and mononuclear cells. Unlike Polyarteritis Nodosa (PAN), MPA involves smaller vessels (capillaries, venules, arterioles) and is typically "pauci-immune" (minimal immunoglobulin deposition). **2. Why the Incorrect Options are Wrong:** * **A. Giant cells and macrophages:** These are characteristic of **Large Vessel Vasculitis**, such as Temporal (Giant Cell) Arteritis or Takayasu Arteritis, which present with granulomatous inflammation rather than acute fibrinoid necrosis. * **C. Micro abscesses:** These are typically seen in infectious processes or specific conditions like Cat-scratch disease or certain fungal infections, not as a primary feature of ANCA-associated vasculitis. * **D. Mycotic aneurysms:** These are dilations of the arterial wall due to an **infection** (bacterial or fungal) weakening the wall. While Polyarteritis Nodosa (PAN) causes "micro-aneurysms," they are not "mycotic" (infectious) in origin. ### **High-Yield Clinical Pearls for NEET-PG** * **Microscopic Polyangiitis (MPA):** Characterized by P-ANCA positivity, necrotizing glomerulonephritis (hematuria), and pulmonary capillaritis (hemoptysis). Unlike Granulomatosis with Polyangiitis (GPA), it **lacks** granulomas. * **Pauci-immune:** This term refers to the absence or scarcity of immune complex deposits on immunofluorescence, a key diagnostic feature of ANCA-associated vasculitides. * **Palpable Purpura:** The classic cutaneous manifestation of small-vessel vasculitis (leukocytoclastic vasculitis).
Practice by Chapter
Rheumatoid Arthritis
Practice Questions
Spondyloarthropathies
Practice Questions
Systemic Lupus Erythematosus
Practice Questions
Vasculitis Syndromes
Practice Questions
Scleroderma and Related Disorders
Practice Questions
Inflammatory Myopathies
Practice Questions
Crystal Arthropathies
Practice Questions
Osteoarthritis
Practice Questions
Primary Immunodeficiency Disorders
Practice Questions
Autoinflammatory Syndromes
Practice Questions
Sjögren's Syndrome
Practice Questions
Antiphospholipid Syndrome
Practice Questions
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